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Monitoring System Equipment certification For Use By Al/Jurisdictions Within The State of California All thurdjt Ciledi Chtip ter 0,7, Htoo Ith and Steftly Corte; Chapter 16, Division 3. Tule 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator- The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name! Safeway 2707 Bldg.No.! Site Address: 6425 N. Pacific Ave. @ Central Ct, City: Stockton, CA Zip: 952047- FacllityCornet Person: Stan Contact Phone No.: (209) 472.8600 Makc/Model of Monitoring System: VIRTLS-350 Date of Testing/Servicing: 4120104 R. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: -rank fD:01-Regu Tank ID: 02-Prem Pg In-T1nk(.1auging Probc, Model: VR 867390-189 29 In-Tank Gauging Prubu. Model: VR 847390-109 N Annular Space ur Vault Serixor. MedC1: VR 796390460 Ijg Annular Sp3cc or Vault Sensor, Model: VR 786390481) N Piping Sunlp\Trench Senior(s). Model: VR7943804200 ® Piping Sump\Trench Sensor(s). Model VR 7114380-2011 09 Fill Sump Sensor(s). Model: VR794380.208 N Fill Sunip Sensor(s). Model: VR 794380.208 ❑ Mechanical Line Leola Detector. Mndcl: Non. p Mechanical Linc Usk Detector. Model: None gg Electronic tine l,mK Ucteactor. Modu l: VR8411480-001 2g ElectIonic Line Leak Dace[or. Model: VR 446490.001 ❑ Tank Overfill\I nigh-Level Sensor. Model: N.. ❑ Tank Overfill\High-Lend Sensor. Model: None ❑ Other(apucil'y equipment type and model in Section E on Page 21. ❑ Other(specify equipment type and rnodel in Section E nn Page 2). Tank ID: 03-Diesel Tank IQ:- go In-Tank Gauging Rnbu. Mndcl: vR 847390.109 ❑ In-'funk Gauging Probe Model: 7 9 Annular tipace or Vault Scnmr. Mnd,elVR 794390460 ❑ Ann ube S pace or Va u l t gerv.r. Model: 9 9 Piping Sump Trench Scnsur(s). Model: VR 794390,208 ❑ Piping Sump t Trench Sensor(s), Madel: 7 z Fill Sunlp Sensor(s). Model: vR 7943aoaos ❑ rill Sump Sensor(S). Model: 1 ❑ Mechanical Line Leak Detector. MNIc7: None ❑ Mcnhsniml I inn Ina lr[lei 1)r lar Meder 4 3 F'leetmnie line Leak Detector. Model: VR 848400401 ❑ Elechvniu Linc Leak Detector. Model: 4 M Tank Overfill\I ligh-Lavol Sensor. Model: No.. ❑ "Tank Ovcrtill High-Level Sensor. Madel: 7 ❑ Other(specify equipment type and model in Section E on Page 2). n Othct'(specify equipment type and model In Section E on Page 21. Dispenser 1D: 01.01 Dispenser ID 03.04 00 Dispenser C'nnlainn,cnt Scnsor(s). Model: VR 794380-208 Ig Dixpensur C(uvainn,ent Sensor(s). Model: vR7943110a09 ❑ .';hear Valve(sl. [I5ncar Val,•o(s). ❑ Dispenser Containment Flout(s)and Chain(s). ❑ Dispenser Containment Float(sl and Chain(s). Dispenser ID: 05.06 Dispenser 1D• 07.06 ill Dispenser Cuntainnwnt Scnsor(s). Model: VR794390-208 S Dispenser Containment Sensor(s), Model- VR 794380.208 ❑ Shear Valvc(s). ❑ Shcar Valve(a), ❑ Dispeatser Containment Float(s)and Chain(s). ❑ Dispenser C-ontoinn,cnt Float(a)and Chain(s). Dispenser ID- 08-10 Dispenser ID 11.12 29 Dlspcnser Containment Sensar(s). Model: VR 794380-20e 22 Dispunscr Cnntainincnt Sensor(s). Mndel: VR794380.209 ❑ Sh,mr Vay.(v) ❑ 6h9ar Volvo(a), ❑ Dispereser Cnntninmm�t Plual('s)and Chain(s), ❑ Dispcnscr Conlainnlcnt Float(s)anti Chain(s). *11'the laci lily contains murc tunks Ord ispcnscrs,copy this dorm.Include infoniiatlon for every tank and dispenser at the facility C. Certification- t cettify that the equipment identified in this document was inspected/serviced in accordance with the Atta.h.a to this Continuation ix information(e.g.inanufacture checklists)necessary to verify Char this information is correct and a Plot Plan showing the layout of monitoring equipment- For tiny cquipmentcapableof generating such reports.I have also anached a cupy of the; (Check all that apply)' O systelll set-up ❑ Alain,history report Technician Name(print): SSS-Talbott Signature: Certification No,: 000-00-5772 License.No.: 485184 Testing Company Name: Ser.Sta. Sys, Phone No.: (408) 971.2445 Skc Address: 6425 N. Pacific Ave. Q Central Ct. Date of Testing/Servicing: 4120104 b0 39vd 9NI SSS SETOTL680b 99:9T 1700Z/0Z/90